Depression, Anxiety and Eating Disorder-Related Impairment: Moderators in Female Adolescents and Young Adults

International Journal of Environmental Research and Public Health Article Depression, Anxiety and Eating Disorder-Related Impairment: Moderators in Female Adolescents and Young Adults Johanna Sander * , Markus Moessner and Stephanie Bauer Center for Psychotherapy Research, Heidelberg University Hospital, 69115 Heidelberg, Germany; [email protected] (M.M.); [email protected] (S.B.) * Correspondence: [email protected]; Tel.: +49-6221-5638170 Abstract: Adolescents and young adults, particularly females, are highly vulnerable to the development of anxiety disorders, depression, and eating disorders. Comorbid anxiety disorder or depression in eating disorders are associated with greater symptom severity, poorer prognosis, and burden of illness. Nonetheless, studies on what affects the relationship between anxiety, depression, and eating disorders in female at-risk samples are scarce. Using hierarchical linear modeling, the present study examined potential moderators to explain between-person differences in the association between anxiety, depression, and eating disorder-related impairment within 12- to 25-year-old females (N = 320). High impairment in anxiety/depression was associated with more severe eating disorder symptoms. Older age as well as greater impairment in mood dysregulation, self-esteem, and perfectionism were linked to more severe eating disorder symptomatology. Whereas mood dysregulation, self-esteem, and perfectionism had no statistically significant moderating effects, younger age appeared to aug- ment the association of anxiety/depression and eating disorder symptomatology. Preventive care in particular needs to consider age-related effects as eating disorder symptoms are associated more Citation: Sander, J.; Moessner, M.; strongly with symptoms of anxiety and depression in early adolescence. Bauer, S. Depression, Anxiety and Eating Disorder-Related Impairment: Keywords: eating disorders; depression; anxiety; adolescence; perfectionism; self-esteem; mood; Moderators in Female Adolescents emotion regulation and Young Adults. Int. J. Environ. Res. Public Health 2021, 18, 2779. https:// doi.org/10.3390/ijerph18052779 1. Introduction Academic Editors: Tyler Mason, Kathryn Smith and Jason Lavender Adolescence is a phase of profound socioaffective and neurocognitive changes reach- ing into early adulthood which is accompanied by a heightened vulnerability for onset of Received: 30 November 2020 mental problems and disorders [1,2]. Female adolescents and young adults are particularly Accepted: 2 March 2021 at risk for eating disorders [3,4]. In a large Austrian sample, 31% of female adolescents aged Published: 9 March 2021 10 to 18 years were found to be at risk to develop an eating disorder [5]. In young women, eating disorder symptoms are highly prevalent. Ward and colleagues estimated the disease Publisher’s Note: MDPI stays neutral dynamics of eating disorders up to the age of 40 based on nationally representative US with regard to jurisdictional claims in survey data and found the highest annual prevalence at age 21, with initial onset mostly published maps and institutional affil- before the age of 25 [6]. High vulnerability for eating disorders in this age group is marked iations. by specific risk factors such as body dissatisfaction and body image concerns. Anxiety disorders and depression are among the most prevalent mental disorders in adolescence [7]. Both are the most common comorbid diagnoses in eating disorders [8,9], especially in adolescence [10]. In a recent study on 15- to 25-year-old females, those with Copyright: © 2021 by the authors. lifetime major depressive disorder or anxiety disorder were four times more likely to have Licensee MDPI, Basel, Switzerland. a lifetime eating disorder [11]. This article is an open access article Similar to anxiety disorders, individuals with an eating disorder use dysfunctional distributed under the terms and strategies such as disordered eating to cope with their emotions [12]. In addition, persisting conditions of the Creative Commons comorbid anxiety symptoms after eating disorder remission increase risk of relapse [13] Attribution (CC BY) license (https:// as individuals revert to former eating disorder-related coping behaviors [14]. In female creativecommons.org/licenses/by/ adolescents and young adults, comorbid anxiety disorders are associated with greater 4.0/). Int. J. Environ. Res. Public Health 2021, 18, 2779. https://doi.org/10.3390/ijerph18052779 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2021, 18, 2779 2 of 12 eating disorder psychopathology [15]. Specifically, comorbid social anxiety hampers recovery efforts as avoidance of interpersonal situations and fears of negative evaluations interfere with treatment engagement and building a good therapeutic relationship [16]. Increasing prevalence rates are reported for depressive disorders in adolescents and young adults, e.g., in the US [17], the UK [18], and Finland [19], especially in girls [20]. Con- cerns about and negative perception of oneself as well as one’s appearance are associated with onset and maintenance of eating disorders and depression [21,22]. Poor therapeutic outcome may be explained by symptoms that reinforce each other: dysfunctional social interaction patterns in depression lead to negative interpersonal experiences that increase the risk for dysfunctional emotion regulation (i.e., disordered eating) [23]. In line with this, eating pathology aggravates with greater severity of affective symptoms [24,25], and depressed mood improves with weight restoration [26]. In summary, evidence supports a strong relationship between anxiety, depression, and eating disorders. Comorbid depression and anxiety symptoms in eating disorders are a marker of greater symptom severity and poorer prognosis and outcome, particularly in young females. To date, only a few studies have explored the differences between individuals with clinical eating disorders with and without comorbid depression and anxiety disorders, e.g., [27–29]. A more recent study identified factors such as a restrictive eating disorder subtype and a deterioration of the general health status relative to one year ago as well as medical comorbidities and low educational level as critical causes for anxiety and depression in adult outpatient eating disorder patients [30]. Nevertheless, studies with adolescent samples exploring the link between anxiety, depression, and eating disorder symptomatology going beyond demographic or clinical characteristics (e.g., age at onset, bingeing, and vomiting frequency) are scarce. Theoretical models that have received the most empirical support are based on the assumption that anxiety, depression, and eating disorders are characterized by a shared etiology [12]. In the present study, the focus is on three aspects that are associated with eating disorders and play a role in the development and maintenance of anxiety disorders and depression. To be more precise, the present study investigates whether these factors moderate the relation between eating disorders and anxiety/depression. Emotion regulation describes the awareness and recognition as well as the attempt to regulate emotional states in accordance with regulation-related goals [31,32]. Evidence suggests that dysfunctional regulation serves as a transdiagnostic risk and maintenance factor involved in several mental disorders including anxiety, depression, and eating disorders [31]. Maladaptive regulation strategies (e.g., avoidance) are associated with more severe psychopathology in all three disorders [31,33]. It is suggested that disordered eating behaviors themselves are maladaptive strategies to regulate negative emotional states [31]. For instance, higher levels of anxiety and depression may lead to the use of dysfunctional emotion regulation strategies such as disordered eating (e.g., bingeing), possibly resulting in greater eating disorder psychopathology and vice versa. As experience of stress and negative emotions heightens, adolescents and young adults are in greater need of effective emotion regulation [34], and a dysfunctional emotion regulation may be particularly problematic in this age group [35]. In the transdiagnostic theory of eating disorders, low self-esteem and perfectionism are key maintaining factors [36]. The former describes a pervasive negative view, concepts, and beliefs about one’s self-worth [36]. Low self-esteem is linked to negative perception of one’s body and body dissatisfaction, i.e., prominent risk factors for eating disorders [37]. In addition, eating disorder symptoms aggravate low self-esteem as well as negative affect and negative social evaluation (e.g., fear of negative evaluations by others) [38]. Particularly in girls, low self-esteem was found during adolescence and increasing with age [39,40]. Low self-esteem affects a range of health outcomes [41] and presents a prospective risk factor for the development of depression in adolescents and young adults [37,42,43]. Low self-esteem is also characteristic of patients with anxiety disorder [44,45]. Int. J. Environ. Res. Public Health 2021, 18, 2779 3 of 12 Perfectionism is a multidimensional concept encompassing the pursuit of high standards and critical self-evaluation when failing to achieve these standards [46]. According to Fairburn et al.’s transdiagnostic theory, perfectionism is another key maintaining factor for eating disorders [36]. Perfectionism significantly

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